Applicant to Read and Sign Prior Topre-Employment Medical Assessment

Aviation Security Service of New Zealand
Pre-employment Health Questionnaire
Surname: – Mr./Mrs./Miss./Ms.
(if changed recently, give previous surname in brackets)
Given Names:
Gender:
Postal Address:
Date of Birth:
Occupation:
Home Number:
Work Number:
Cellphone:

Medical History – Have you ever had any of the following? Circle for every condition you have ever had in your life

(a) / YES / NO / Migraine: frequent or severe headaches; Dizziness or fainting spell; Unconsciously for any reason; Concussion (head injury); Neurological disorders e.g. epilepsy, seizures, stroke, or paralysis.
(b) / YES / NO / Eye or vision trouble (or needed new glasses or contact lenses since last examination)
(c) / YES / NO / Hay fever or allergy or ENT problems; Asthma or lung disease or abnormal shortness of breath
(d) / YES / NO / Heart or vascular problems; chest pains or discomfort; Rheumatic fever; High or low blood pressure.
(e) / YES / NO / Hernia, stomach, liver or intestinal trouble; Diabetes; Hepatitis or jaundice.
(f) / YES / NO / Kidney stone or blood in urine
(g) / YES / NO / Mental disorders of any sort e.g. depression, anxiety; Suicide attempt
(h) / YES / NO / Substance dependence, substance abuse or use of illegal substance; Alcohol dependence or abuse.
(i) / YES / NO / (Females) any period or gynaecological troubles, or pre-menstrual tension.
(j) / YES / NO / Muscle, bone or joint disorder, swollen or painful joints.
(k) / YES / NO / Rejection or retirement from employment on medical grounds; Rejection or premium loading for life or health insurance.
(l) / YES / NO / Admission to hospital; Other illness, disability or surgery
If you answered yes to the above, please provide details:

Visits to health professional within the last 3 years? (Please circle) YES NO

Date / Name of Healthcare Professional / Reason

APPLICANT TO READ AND SIGN PRIOR TOPRE-EMPLOYMENT MEDICAL ASSESSMENT

I consent to the release to the Aviation Security Chief Medical Advisor any medical information relating to me, held by any practitioner, hospital or other organization.

This consent is given on the understanding that the purpose of such release will be restricted to the assessment of fitness for the duties as Aviation Security Officer.

I further consent to the resulting assessment being provided to the employing service involved.

I undertake that the information to be provided at this (or other) examination will be correct to the best of my knowledge, and I will not withhold any relevant information.

I am aware that failure by me to give correct information above may jeopardize my employment and my right to any insurance on the basis of this examination, or to compensation, when incapacity is related to such information.

Applicant’s Signature: Date
Witnessed (Medical Examiner): Date